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E Body Art Inspection Report Date(MM/DD/YY) la_-7_1 y County of San Joaquin County,Environmental Health Department u, < 1888 E.Hazelton Ave.,Stockton CA 95205 Permit Number �� (209)488-3420 www.siaov.oro/ehd Permit Type tit a Facility Name Address City Zip Code CT Permit/Registration Holder Name Permit Exp.Date Total Time Inspection Type RISK FACTORS AND INTERVENTIONS Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. y In=1n Compliance Out=Not in Compliance N/O=Not Observed N/A=Not Applicable COS=Corrected On Site , uRl ;_I~ C(3SMETiGrS HIKE s , C-QWlNG;AN STE9NlZAT161,. In N10 1. Autoclave is approved and effective-passed ❑ ❑ in 18. Safe machine design ❑ ❑ N/A inteqrator test I N/A In N/0 2. Process of cleaning,labeling,packaging and ❑ In 19. Machines cleaned and disinfected between ❑ ❑ NIA stediziing items correct) N! clients In N/0 3. Autoclave loaded correctly/packages allowed to ❑ In F 20. Parts replaced between clients-grommets, ❑ ❑ NIA dry N elastic bands,etc. In N/O 4. Integrators used/monthly spore testllog t 0-6 '6=01WAM IN ❑ .rs � r NIA maintained , In N/O 5. Decontamination/sanitation area separate and ❑ ❑ In21. Workstation/procedure area decontaminated 13 13N/A supplied* NIV In N/0 6. Invoices and log kept for disposable,pre- ❑ ❑ In N/0 22. Chemical disinfan used 13 13N/A sterilized equipment,backupsupplies available* NIA Chemical used: In N10 7. Sharps containers supplied,labeled,used and ❑ In WO 23. Disinfectant used sufficient contact time Wet ❑ ❑ N/A disposed of correct) * N/A contact timeprovided: L9 in N/O 8. Jewelry,tattoo and piercing equipment-storage ❑ ❑ in XV 24. Barriers available and used as part of ❑ ❑ NIA and use procedure I % �� n t0 25. Products applied to skin are single ❑ ❑ ,?k1AXITI4NE�t EAT �iD,HfGll:h~ ,,. . ` � ...m�r,.. N/A use/dispensed ensed aseptically In N/0 9. No eating,drinking or smoking-clean clothes ❑ ❑ In N10 26. Storage of inks,pigments,needles,tubes,etc., ❑ ❑ N/A NIA In 0 10. Hands washed effectively and timely El In N/O 27. Jewelry,Inks,Needles etc approved and used 13 13 NIA I N/O 11. Handwashing facilities properly supplied and .L ❑ In N/0 28. Cross-contamination avoided during all phases 1313N/A accessible,warm potable water* NIA of procedure In N/0 12. Personal protective equipment available and ;�BSll3'Sl °PTlS7 ,}t 3 ❑ ❑ NIA used,eyewash station available Ro . in N/0 29. Areas separated/no living or sleeping . `=r Eft N/A quarters/no animals* 11 11M-111 ., 11 In NIO 13. Branding is completed with no other customers in ❑ ❑ In N/0 30. Floors and walls clean and in good repair, ❑ ❑ procedure area NIA adequate light* n N10 14. Customers eighteen(18)years of age or older ❑ ❑ In N10 31. Workstation,surfaces,including chairs,,etc.in ❑ ❑ N/A N/A good repair;trash removed frequently* In & 15. Skin prepared for procedure. ❑ ❑ in N/0 32. Permitiregistration and required signs posted* ® ❑ NIA I I NIA In N/O 16. Client records available-Consent form& ® In N/0 33. IPCP and employee training records and ❑ N/A questionnaire N/A Hepatitis B vaccination status present In N/0 17. Aftercare instructions given to client In N/0 34 Resttooms available,stocked NIA ® N/A ❑ ❑ Received b Print Received b Si nature: Phone: Specialist(Print): Sp ' list(Signature): Phone: This report is an Official Notice of Violation.Corrections must be completed in the time specified. A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Page I of_